Standard Health Record FHIR Implementation Guide

SHR SurgicalProcedurePerformed Profile - Detailed Descriptions

Definitions for shr-procedure-SurgicalProcedurePerformed.

Procedure
Definition

The US Core Condition Profile is based upon the core FHIR Procedure Resource and created to meet the 2015 Edition Common Clinical Data Set 'Procedures' requirements.

Control0..*
InvariantsDefined on this element
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
pro-1: Reason not done is only permitted if notDone indicator is true (: notDoneReason.empty() or notDone = true)
Procedure.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Procedure.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Procedure.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

Procedure.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Procedure.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

Procedure.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Procedure.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.extension (http://hl7.org/fhir/StructureDefinition/procedure-approachBodySite)
Definition

The approach body site used for this procedure. Multiple locations are allowed.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(BodySite))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://hl7.org/fhir/StructureDefinition/procedure-targetBodySite)
Definition

The target body site used for this procedure. Multiple locations are allowed.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(BodySite))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-RelatedEncounter-extension)
Definition

If content was generated during a patient encounter, related encounter is the encounter where the information was gained.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR EncounterPerformed Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension)
Definition

The person or organization who created the entry and is responsible for (and may certify) the content.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-base-Author-extension SHALL have either extension('string') or extension('patient') or extension('group') or extension('device') or extension('participant') or extension('relatedperson') or extension('organization') (: ( extension('string').url | extension('patient').url | extension('group').url | extension('device').url | extension('participant').url | extension('relatedperson').url | extension('organization').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Informant-extension)
Definition

The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-base-Informant-extension SHALL have either extension('string') or extension('patient') or extension('group') or extension('device') or extension('participant') or extension('relatedperson') or extension('organization') (: ( extension('string').url | extension('patient').url | extension('group').url | extension('device').url | extension('participant').url | extension('relatedperson').url | extension('organization').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-Type-extension)
Definition

The most specific code (lowest level term) describing the kind or sort of thing being represented.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.extension.extension(extension)
Definition

An Extension

Control0..0
TypeExtension
Procedure.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-Type-extension
Procedure.extension.valueCodeableConcept
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control1..1
Bindingnull
The codes SHALL be taken from US Core Procedure Codes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-core-Category-extension)
Definition

A class or division of people or things having particular shared characteristics

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-action-PerformedContext-extension)
Definition

ActionContext indicating actual performance or execution of a healthcare-related action, e.g., 3rd dose of Hepatitis B vaccine administered on Dec 4th 2012, appendectomy performed today.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Subject-extension)
Definition

The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-base-Subject-extension SHALL have either extension('patient') or extension('group') or extension('device') or extension('location') or extension('relatedperson') or extension('organization') (: ( extension('patient').url | extension('group').url | extension('device').url | extension('location').url | extension('relatedperson').url | extension('organization').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.extension.extension
Definition

An Extension

Control0..*
TypeExtension
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-Patient-extension)
Definition

A person in the role of a patient, including extended demographic information about the subject of this health record.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Patient Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-Group-extension)
Definition

A set of entities (personnel, material, or places) to be considered together. May be a pool of like-type resources, a team, or combination of personnel, material and places.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Group Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-device-Device-extension)
Definition

A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Device Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-core-Location-extension)
Definition

A position, site, or point in space where something can be found.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-core-Location-extension SHALL have either extension('address') or extension('geoposition') or extension('geopoliticallocation') (: ( extension('address').url | extension('geoposition').url | extension('geopoliticallocation').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-RelatedPerson-extension)
Definition

A person in a role defined in relationship to a patient

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR RelatedPerson Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-Organization-extension)
Definition

A social or legal structure formed by human beings.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Organization Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Subject-extension
Procedure.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..0
TypeChoice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-BodySite-extension)
Definition

A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR BodySite Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-AssociatedStudy-extension)
Definition

The clinical trial or other formal study related to this procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Study Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-PartOf-extension)
Definition

The larger entity that this is a portion of.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.extension.extension
Definition

An Extension

Control0..*
TypeExtension
Procedure.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Content-extension)
Definition

An item that can constitute the payload of an Entry, aka an EntryElement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.extension.extension.extension
Definition

An Extension

Control0..*
TypeExtension
Procedure.extension.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-RelatedEncounter-extension)
Definition

If content was generated during a patient encounter, related encounter is the encounter where the information was gained.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR EncounterPerformed Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension)
Definition

The person or organization who created the entry and is responsible for (and may certify) the content.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-base-Author-extension SHALL have either extension('string') or extension('patient') or extension('group') or extension('device') or extension('participant') or extension('relatedperson') or extension('organization') (: ( extension('string').url | extension('patient').url | extension('group').url | extension('device').url | extension('participant').url | extension('relatedperson').url | extension('organization').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Informant-extension)
Definition

The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
choice-1: shr-base-Informant-extension SHALL have either extension('string') or extension('patient') or extension('group') or extension('device') or extension('participant') or extension('relatedperson') or extension('organization') (: ( extension('string').url | extension('patient').url | extension('group').url | extension('device').url | extension('participant').url | extension('relatedperson').url | extension('organization').url ).distinct().count() == 1)
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Content-extension
Procedure.extension.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..0
TypeChoice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Procedure.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://standardhealthrecord.org/fhir/StructureDefinition/shr-entity-PartOf-extension
Procedure.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..0
TypeChoice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-core-Annotation-extension)
Definition

An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Annotation(SHR Annotation Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-DirectSiteCode-extension)
Definition

The site where the procedure is performed.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-IndirectSiteCode-extension)
Definition

The indirect site for this procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-Access-extension)
Definition

The route used to access the site of a procedure. It is used to distinguish open, closed, and percutaneous procedures.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-UsingDevice-extension)
Definition

The device used to perform the procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Device Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-UsingDeviceCode-extension)
Definition

The device used to perform the procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-UsingAccessDevice-extension)
Definition

The access device used to perform the procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Device Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-UsingAccessDeviceCode-extension)
Definition

The access device used to perform the procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-IndirectDevice-extension)
Definition

An indirect device used for this procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(SHR Device Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.extension (http://standardhealthrecord.org/fhir/StructureDefinition/shr-procedure-IndirectDeviceCode-extension)
Definition

An indirect device used for this procedure.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Procedure.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.identifier
Definition

This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Procedure.definition
Definition

A protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure.

Control0..*
TypeChoice of: Reference(PlanDefinition), Reference(ActivityDefinition), Reference(HealthcareService)
Procedure.basedOn
Definition

A reference to a resource that contains details of the request for this procedure.

Control0..*
TypeChoice of: Reference(CarePlan), Reference(ProcedureRequest), Reference(ReferralRequest)
Alternate Namesfulfills
Procedure.partOf
Definition

A larger event of which this particular procedure is a component or step.

Control0..*
TypeChoice of: Reference(Procedure), Reference(Observation), Reference(MedicationAdministration)
Alternate Namescontainer
Comments

The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration.

Procedure.status
Definition

A code specifying the state of the procedure. Generally this will be in-progress or completed state.

Control1..1
Bindingnull
The codes SHALL be taken from EventStatus
Typecode
Is Modifiertrue
Must Supporttrue
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Procedure.notDone
Definition

Set this to true if the record is saying that the procedure was NOT performed.

Control0..1
Typeboolean
Is Modifiertrue
Comments

If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome.

This element is labeled as a modifier because it indicates that a procedure didn't happen.

Default Valuefalse
Procedure.notDoneReason
Definition

A code indicating why the procedure was not performed.

Control0..1 This element is affected by the following invariants: pro-1
BindingA code that identifies the reason a procedure was not performed.
For example codes, see Procedure Not Performed Reason (SNOMED-CT)
TypeCodeableConcept
Procedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Control0..1
BindingA code that classifies a procedure for searching, sorting and display purposes.
For example codes, see Procedure Category Codes (SNOMED CT)
TypeCodeableConcept
Procedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Control1..1
BindingCodes describing the type of Procedure
The codes SHALL be taken from US Core Procedure Codes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Procedure.subject
Definition

The person, animal or group on which the procedure was performed.

Control1..1
TypeReference(US Core Patient Profile)
Must Supporttrue
Alternate Namespatient
Procedure.context
Definition

The encounter during which the procedure was performed.

Control0..1
TypeChoice of: Reference(Encounter), Reference(EpisodeOfCare)
Alternate Namesencounter
Procedure.performed[x]
Definition

The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Control1..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Procedure.performer
Definition

Limited to 'real' people rather than equipment.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Procedure.performer.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.performer.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.role
Definition

For example: surgeon, anaethetist, endoscopist.

Control0..1
BindingA code that identifies the role of a performer of the procedure.
For example codes, see Procedure Performer Role Codes
TypeCodeableConcept
Procedure.performer.actor
Definition

The practitioner who was involved in the procedure.

Control1..1
TypeChoice of: Reference(Practitioner), Reference(Organization), Reference(Patient), Reference(RelatedPerson), Reference(Device)
Requirements

A reference to Device supports use cases, such as pacemakers.

Procedure.performer.onBehalfOf
Definition

The organization the device or practitioner was acting on behalf of.

Control0..1
TypeReference(Organization)
Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Procedure.location
Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Control0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Procedure.reasonCode
Definition

The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text.

Control0..*
BindingA code that identifies the reason a procedure is required.
For example codes, see Procedure Reason Codes
TypeCodeableConcept
Procedure.reasonReference
Definition

The condition that is the reason why the procedure was performed.

Control0..*
TypeChoice of: Reference(Condition), Reference(Observation)
Comments

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.

Procedure.bodySite
Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Control0..*
BindingCodes describing anatomical locations. May include laterality.
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Procedure.outcome
Definition

The outcome of the procedure - did it resolve reasons for the procedure being performed?

Control0..1
BindingAn outcome of a procedure - whether it was resolved or otherwise.
For example codes, see Procedure Outcome Codes (SNOMED CT)
TypeCodeableConcept
Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Procedure.report
Definition

This could be a histology result, pathology report, surgical report, etc..

Control0..*
TypeReference(DiagnosticReport)
Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Procedure.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Control0..*
BindingCodes describing complications that resulted from a procedure.
For example codes, see Condition/Problem/Diagnosis Codes
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Procedure.complicationDetail
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Control0..*
TypeReference(Condition)
Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Procedure.followUp
Definition

If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.

Control0..*
BindingSpecific follow up required for a procedure e.g. removal of sutures.
For example codes, see Procedure Follow up Codes (SNOMED CT)
TypeCodeableConcept
Procedure.note
Definition

Any other notes about the procedure. E.g. the operative notes.

Control0..*
TypeAnnotation
Procedure.focalDevice
Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Procedure.focalDevice.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Procedure.focalDevice.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.focalDevice.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.focalDevice.action
Definition

The kind of change that happened to the device during the procedure.

Control0..1
BindingA kind of change that happened to the device during the procedure.
The codes SHOULD be taken from Procedure Device Action Codes
TypeCodeableConcept
Procedure.focalDevice.manipulated
Definition

The device that was manipulated (changed) during the procedure.

Control1..1
TypeReference(Device)
Procedure.usedReference
Definition

Identifies medications, devices and any other substance used as part of the procedure.

Control0..*
TypeChoice of: Reference(Device), Reference(Medication), Reference(Substance)
Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Procedure.usedCode
Definition

Identifies coded items that were used as part of the procedure.

Control0..*
BindingCodes describing items used during a procedure
For example codes, see FHIR Device Types
TypeCodeableConcept
Comments

For devices actually implanted or removed, use Procedure.device.